Health Education

In addition to reforming the nation's health-care system, The Patient Protection and Affordable Care Act, passed in March, came close to being a major education bill. Funding for an early education program for children under 5, which would have made explicit the connection between education and health, hitched a ride with the health-care reconciliation package until negotiators dropped it at the last minute.

Even without that provision, the health bill holds great promise as a means to dramatically improve early literacy and other educational outcomes, albeit indirectly. Educators and health providers agree that well-fed, healthy children learn better. While experts will continue to debate the exact ways adequate nutrition and health care can lead to better educational outcomes, widespread acceptance that health affects learning helped justify many early nutrition and insurance programs for poor children and pregnant women, from the Women, Infants and Children feeding program through the State Children's Health Insurance Program (S-CHIP). In explicit recognition of this connection, the health-reform bill did include a $1.5 billion home-visitation program, funding nurses to visit homes to educate and provide support for expecting or new parents. This kind of initiative recognizes that the skills needed to create a nurturing environment -- and a learning environment -- aren't natural and that the kind of educational enrichment middle-class families take for granted should be available to everyone.

But there are more basic ways that the health-care-reform effort is likely to lead to better education outcomes, especially in literacy. Put simply, it will bring every last child under the umbrella of health insurance and get parents more involved in their children's health care and overall well-being.

From promoting breast-feeding by requiring employers to provide safe spaces for pumping breast milk, to eliminating lifetime caps on benefits that prevent the sickest children from receiving adequate care, to reducing school absenteeism by ensuring children have better treatment and therefore fewer emergencies -- the health-care reform bill has the potential to make children healthier and, as a result, better learners.

While the link between breast-feeding and better literacy outcomes is not a direct one, most doctors now agree that breast milk is a sort of elixir for babies. A 2008 study from McGill University found that breast-feeding exclusively and for longer periods of time was associated with higher IQs and better educational outcomes. A study published in Pediatrics this year found that breast-feeding also prevents nutritional diseases like diabetes and long-term problems like asthma. Those conditions aren't only costly; they can keep children from learning because they require intense management. For example, as Hedy Chang and Phyllis Jordan write in this report, about one in 10 kindergarten and first-grade students miss 10 percent of the year's classes. And those first years of school provide the building blocks for learning later, especially in literacy. Late in elementary school, children shift from learning to read to reading to learn; nearly every aspect of their subsequent education will be influenced by their ability to read educational materials.

One disarmingly simple provision of a better health-care system that could dramatically improve childhood literacy is ensuring vision testing for all kids and providing glasses to those who need them.

This will come as no surprise to teachers, who know well that many of their students who have trouble reading or paying attention are having trouble seeing. Many schools screen for vision problems, but in the Philadelphia area, for example, about 60 percent of the children who show problems in screening do not receive further eye care. Simply getting those children glasses can have a big effect on their learning ability.

Philadelphia offers a case study in the effort to close the glasses gap, and its effects on literacy. In 1995, the Philadelphia Eagles football team launched a program to provide free eye exams and eyeglasses. "We've noticed since we've had the Eagles Eye Mobile come to us, there's been an increase in our reading skills and also in our math skills for our children," said Kathleen Girbada, a school nurse from the Philadelphia area interviewed in a video on the initiative's website. The mobile clinic provided glasses for children who knew, and whose teachers knew, that they needed them but weren't able to afford them.

Vision care, along with untreated hearing problems, is a bigger obstacle to children's literacy than most Americans know, says Linda Katz, executive director of the Children's Literacy Initiative, also located in Philadelphia. "These aren't at the margins," she says. The numbers of children with untreated vision and hearing problems, and the consequences of those problems, are "getting worse, primarily because of the money."

While for many children, better vision and improved learning is just a matter of getting the right glasses, for others, improved screening and regular access to medical care is necessary to solve problems that often appear to be learning disabilities. Children who can't read the board or their books may have visual-processing disorders like dyslexia that worsen because they go undiagnosed. Children with uncorrected vision problems can overcompensate, making their eyesight worse and causing other health problems like headaches. That can lead to learning blocks that are falsely attributed to behavioral or learning problems. "It's not identified early because kids don't seem to be having trouble: They're not walking into walls a lot, and they seem to be able to watch television," says Shelly Yanoff, executive director of the Public Citizens for Children and Youth. "So the fact that they're not able to identify letters appears to be a learning disability."

There is still a gap in vision care for children in the benefits that are covered under insurance and public health programs. A 2002 report from the Centers for Disease Control and Prevention showed that only a little more than a third of children under 6-years-old had ever had their vision tested. Of all children under age 18, only about 20 percent had visited an eye doctor in the previous year. A recent National Commission on Vision & Health report revealed that 23 percent of children without insurance had unmet vision needs, in part because more than half of children without health insurance do not have regular physicals. Five percent of children who had been insured for a year or more still had unmet vision needs.

For the poor and the uninsured, eye exams and glasses are an expense that cannot be squeezed into the budget. As a result, many children don't resolve vision problems until their adolescence. By the time they first see an eye doctor, they've already been expected to know how to read. Every piece of knowledge in every class will be augmented by or first encountered in a textbook. Untreated vision problems that prevented literacy training, then, can lead to learning problems for the rest of their lives.

Vision care for children is uneven now. Medicaid has very comprehensive vision coverage, but the S-CHIP programs vary from state to state because states can decide on their own S-CHIP regulations, within certain guidelines. And when the benefits aren't mandatory, they're vulnerable. "When ... states are under budget pressures, the very last thing they want to do is cut eligibility," says Julia Paradise, of the Kaiser Family Foundation. "One of the very first options they have is to cut benefits."

Researchers at the Public Citizens for Children and Youth found in a 2008 report that in addition to not being able to afford glasses, many parents are not aware of the severity of their child's vision problems. They either do not understand the diagnosis from school screening programs, or they don't understand the damage a delay in getting glasses can do to their child's ability to learn. Additionally, the report said, parents can misunderstand their benefits and not realize, for example, that their child's glasses can be repaired if they break.

Private plans also vary a great deal. The health-care reform bill does define vision and dental care as an essential ingredient of pediatric care for insurance plans within the private health-insurance exchanges, which will result, eventually, in a standardized minimum package of benefits. What that package will include is not yet clear and will vary from state to state. At the very minimum, though, the law requires that plans cover vision screening as preventive care, with no out-of-pocket costs, for children under 5. "It's a very important gain," Paradise says. "It's an idea that an essential benefits package for children includes vision care, whatever the limitations are."

That basic level of care can also catch other problems. The bill provides for children to have regular doctor visits, and preventative screenings are covered with no cost-sharing. That can catch learning disorders earlier and help children receive continual, adequate treatment. The goal is to bring the last children without access to health insurance into a seamless system of care. It could also close a loophole that allowed family-plan providers to consider many benefits, like vision care for children, as separate from a basic plan. "There will be some sort of a blanket," Yanoff says. "It will give more impetus for all practitioners to do these screenings and follow up."

Moreover, it will make a difference for parents to simply be part of an overarching health-insurance system. If all works as hoped, children will be under the continuous care of a doctor, who will see problems as they develop and know that the family will be able to afford the prescribed remedy. And by bringing the whole family into the same web of care, parents may become more engaged with their children's needs and better able to support them in school or demand that the school provide necessary services -- as middle-class parents have done for years. Vision is just one example of the ways in which a giant step forward for health care might also be a big step for education and literacy.